Basic Information
| Provider Information | |||||||||
| NPI: | 1417280132 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2726 BROWNSBORO RD | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402061265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708232222 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2215 PORTLAND AVE | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402121033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5027748631 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2009 | ||||||||
| LastUpdateDate: | 03/10/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 8707 | KY | Y | Dental Providers | Dentist | General Practice | 122300000X | 12011371A | IN | N | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 7100100150 | 05 | KY | MEDICAID |